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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington <br /> ` iScvnSinSee reverse side for instructions for completing this application PO Box 7 <br /> Department of Commerce <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7' [Privacy Law,s. 15.04(1)(m)] (Submit completed p eted form to county if <br /> state owne <br /> Attach comptete PTans to the county copy only)for system,on paper not less than 8-1/2 x 11 inches in size. ma <br /> County +, State Sanitary Pe it u er C eck if retvision to prev s application State Plan I.D.Number <br /> LT Lt rr7{ a <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> t.//W?"J tl NJ"1/4 Ivi 1/4,S 14 T 190,N,R17E or 60 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 76 3? Co. /AQP. U- G, r 107— A <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Weba �/�/L J ��g.3 7�S 8b6 73// 6j'� er_f <br /> II.Type of Building: (check one) ❑City <br /> lid 1 or 2 Family Dwelling-No.of Bedrooms;f� ❑Village <br /> ❑ Public/Commercial(describe use): WTown of <br /> ❑ State-Owned L(h Ion <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> 4,e u <br /> A) New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tk� <br /> ExistingSystem ®36 'Yo `l &t S`d0 <br /> B) ber Date Issued <br /> ❑A Sanita Permit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑ Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area T 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 969 96fs f S�Gw ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) I Plumber's <br /> Signature(no sta M <br /> s): P/MPRS No. Business Phone Number <br /> �IG�rn�cY /Te klol W +�! -ZZsa�;-1 '71..S-- 9'6,G—4.s--> <br /> Plumbers Address(Street,City,State,Zip C de) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pem.W Fee(Includes Groundwater Date Issued Issuing Age Sign mps) <br /> N-Approved ElOwner Given Initial Adverse Surcharge F UJ� m d <br /> Determination pe lY �-��— 1 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br />